Tobacco use is the leading cause of preventable death in the U.S.,1 and health authorities warn that while traditional (combustible) cigarette use has declined,2 the number of teens using e-cigs, also known as vaping, has steadily risen in recent years.

Between 2011 and 2015, vaping among high school students rose by an astounding 900 percent.3 According to the 2018 National Youth Tobacco Survey,4 3.6 million teens are now vaping.5 A high schooler quoted in The New Yorker expresses a common view when he says that while smoking is "gross … Juuling is really what's up."6 FDA commissioner Dr. Scott Gotttlieb commented on the findings, saying:7

"These data shock my conscience: From 2017 to 2018, there was a 78 percent increase in current e-cigarette use among high school students and a 48 percent increase among middle school students.

The total number of middle and high school students currently using e-cigarettes rose to 3.6 million — that's 1.5 million more students using these products than the previous year.

Additionally, more than a quarter (27.7 percent) of high school current e-cigarette users are using the product regularly (on 20 or more days in the past month). More than two-thirds (67.8 percent) are using flavored e-cigarettes. Both these numbers have risen significantly since 2017."

Unfortunately, the general perception is that e-cigs are safer than traditional cigarettes. Research does not bear this out, however. It's really important to realize there are no safe tobacco products, be they smokeless or combustible.

Underage Vaping Prompts New Restrictions

In an undercover investigation conducted over the summer, the U.S. Food and Drug Administration (FDA) issued warnings and fines to more than 1,300 stores for the illegal sale of vaping products to minors.8

To rein in the use of e-cigs among children and teens, the agency recently announced it will restrict sale of sweet-flavored vaping products in convenience stores and gas stations.9,10 Stores selling child-friendly e-cig flavors must keep the products in an age-restricted section and must have age verification measures in place to prevent underage sale.

While e-cig makers insist they're not targeting youth, their marketing tells a different story. The marketing of child-friendly flavors alone is evidence of this. As noted by Meghan Morean, a psychology professor at Oberlin College who has studied the appeal of flavors, "We're not reinventing anything here, we've already lived this … It's the exact reason that flavored cigarettes were banned."11 Health and Human Services secretary Alex Azar echoed this sentiment in a statement, saying:12

"Flavors are a major reason they use these products in the first place. Flavors increase the likelihood of kids progressing from experimentation to regular use, and a portion of them will go on to use combustible tobacco products, with the huge added dangers of tobacco-related disease."

The policy will also cover flavored cigar products introduced between 2007 and 2016, and menthol cigarettes. If the manufacturer wants to continue selling these products, they must apply for FDA approval.

The FDA urges manufacturers to voluntarily remove their products from locations where children and teens can access them within the next 90 days, although it may take several months before the restrictions officially go into effect. The FDA is also proposing tighter rules on the use of cartoons and naming of products that might appeal to youth.

E-Cig Makers Announce Plans to Cut Back Marketing and Sales to Teens

Juul — which has cornered three-quarters of the e-cig market — has announced its plan to remove child-friendly fruit- and dessert-flavored nicotine pods from retail stores.

The company is also suspending its Facebook and Instagram promotion, and says it will prevent underage users from purchasing the products online by cross-checking the purchaser’s date of birth and last four digits of their Social Security number against public records.

While this is good news, it seems the company is only reacting to overwhelming pressure and bad press. As reported by The New York Times:13

"'Our intent was never to have youth use Juul,' said Kevin Burns, chief executive of Juul Labs in a statement emailed to reporters. 'But intent is not enough. The numbers are what matter and the numbers tell us underage use of e-cigarettes is a problem.'

But critics and public health advocates said the company had no choice, especially after the FDA raided its headquarters last month seeking documents related to marketing and came under by some states investigating whether its tactics were directly aimed at minors.

Caroline Renzulli, a spokeswoman for the Campaign for Tobacco-Free Kids, called Juul's announcement too little too late. 'Juul's social media marketing fueled its popularity with kids … Now that it has captured 75 percent of the e-cigarette market, Juul no longer needs to do social media marketing because its young customers are doing it for them.'"

R.J. Reynolds Tobacco Co., the maker of Vuse vaping devices, has submitted a similar plan to the FDA, promising to suspend marketing through social media influencers; require age-verification for access to its online store; enforce penalties for retailers selling the products to youths; and to check for compliance through a mystery shopping program. The manufacturer of Blu e-cigs, Fontem Ventures, says it will raise the minimum age to buy e-pods online to 21.

How Juul Brought Smoking Back

Juul — represented as the "most genuine alternative to smoking cigarettes"14 — is now so popular, its use has become a verb; it's not "smoking" anymore, it's "Juuling."

And, while the company claims its primary aim is to help smokers quit the habit, not to introduce smoking to a whole new generation, company statements seem to encourage a switch to vapor and not quitting completely when they say, "adult smokers interested in switching from cigarettes should be offered high-quality alternatives that satisfy them because satisfaction is a key component to supporting their switch to vapor."

These goals resulted in the production of patented JuulSalts delivering a nicotine hit much more like smoking a cigarette than any other e-cigarette product.15 The breakthrough occurred when Juul began using benzoic acid to freebase nicotine salts for rapid nicotine delivery.

Since the 1960s, cigarette companies have freebased nicotine using ammonia, which can be very irritating to the chest and lungs. However freebased nicotine from JuulSalts is not as irritating and is readily absorbed into the lungs and brain.

As a result, Juul has one of the highest nicotine content of any e-cigarette sold in the U.S.16 JuulPod e-liquid cartridges can contain up to twice the amount of nicotine as a pack of cigarettes, and they're just as easy to inhale.17,18 For these reasons, Juul, more so than any other e-cig, poses a significant threat to youngsters.

E-Cigs Cause Nicotine Addiction Just Like Traditional Cigarettes

Vapers who've tried Juuls agree they have a much stronger nicotine hit than other e-cigs. One ex-smoker found that once he started on Juuls, the vaping habit became "remarkably difficult to kick."19 Indeed, as noted by one addiction expert,20 "The modern cigarette does to nicotine what crack does to cocaine."

Further facilitating use, the Juul's built-in battery is charged via a magnetic USB adapter, takes an hour to charge and lasts for 200 puffs (one full day of regular use), and the fruity flavored pods contain 50 milligrams of nicotine while emitting such a mild fragrance, they've been mistaken for a light perfume. While research into the long-term health effects of vaping is still limited, we already know that:21

• Nicotine is more addictive than alcohol and barbiturates.22

• Nicotine affects cognitive development, decision making, emotional control and impulse regulation in children and teens.23

• Brain changes from nicotine also increase sensitivity to other drugs.24

• If addicted to nicotine at a younger age, young people are more susceptible to other addictions later on in life,25 including alcohol.26 According to the researchers, exposure altered the neurological circuitry in the brain's reward pathway.

Administration of nicotine during adulthood did not produce the same alteration in function of the inhibitory midbrain circuitry as did exposure during adolescence. A PLOS One study27 also suggests there's a two to seven times greater possibility that vaping teens will move on to combustible cigarettes.

• When addicted at a younger age, it's harder to quit nicotine, whether it's vaped or a smoking product. One study28 shows that 85 percent of those who try to stop either smoking or vaping end up relapsing.

E-Cigs Are Just as Harmful as Cigarettes

Mounting research also shows e-cigs are just as hazardous to your health as traditional cigarettes. For example, studies have found:

• The liquid used to flavor e-cigarettes may induce early signs of cardiovascular disease leading to heart attack, stroke and even death.29 The scientists found changes appeared almost immediately on the cellular level. One of the key factors in this study was the direct testing of the effect of just flavoring at levels likely to be reached inside the body.

According to lead author Jessica Fetterman, Ph.D., the measures evaluated during data collection were some of the first changes seen in the development of heart disease.30 At the highest level of exposure the chemicals triggered outright cell death. At a lower level, researchers noted impaired nitric oxide production and increased inflammation.

• Vaping devices produce and emit significant levels of toxic lead, nickel, chromium and manganese31 — Nearly 50 percent of the vapor samples contained lead levels higher than limits set by the Environmental Protection Agency (EPA).32 Concentrations of the other three metals either approached or exceeded safety limits set by the EPA.

And, despite the lower levels of nicotine pollution e-cigs produce, researchers found people exposed to e-cigarette air pollution have a similar level of cotinine — a measure of the amount of nicotine taken into the body — as those exposed to traditional secondhand cigarette smoke.35 The reason for this discrepancy remains unclear.

• E-cig vapor also contains acetaldehyde36 and formaldehyde,37 both known carcinogens.38 At least one brand tested had 10 times more than found in traditional cigarettes. The FDA has also detected antifreeze chemicals in e-cigarettes — another known carcinogen.39

• Vaping damages your lungs, increasing your risk for lung disease — The vapor from e-cigs boosts production of inflammatory chemicals and impairs the activity of macrophages, leading researchers to conclude it may damage vital immune system cells.40,41 Many of the effects were similar to those seen in people who regularly smoke and those with chronic lung disease.

How to Make Quitting Smoking Easier

I believe the "secret" to quitting smoking is to get healthy first, which will make quitting mentally and physically easier. Exercising is an important part of this plan, as research shows people who engage in regular strength training double their success rate at quitting smoking compared to those who don't exercise.42

Healthy eating is another crucial factor to improving your health and strengthening your ability to quit. In short, if you want to quit, here are three basic tips to get started:

• Find a healthy emotional outlet. Many use exercise, meditation or relaxation techniques for this, and these are all great. I also recommend incorporating Emotional Freedom Techniques (EFT).

This can help clear out emotional blockages from your system (some of which you might not even realize are there), thus restoring your mind and body's balance and helping you break the addiction and avoid cravings.

Once you are regularly doing these three things, then you can begin to think about quitting smoking. At this point, many are ready to try quitting "cold turkey." If you need a distraction, these six things to do instead of smoking may help. Finally, if you're a parent, talk with your children about the risks of smoking, smokeless tobacco and e-cigarettes. The easiest pathway to not smoking is to avoid starting in the first place.